Provider Demographics
NPI:1669614483
Name:CLINICAL AND FORENSIC PSYCHOLOGY LTD
Entity type:Organization
Organization Name:CLINICAL AND FORENSIC PSYCHOLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HARLAN
Authorized Official - Last Name:GILBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-581-6655
Mailing Address - Street 1:POST OFFICE BOX 67
Mailing Address - Street 2:
Mailing Address - City:BARNUM
Mailing Address - State:MN
Mailing Address - Zip Code:55707
Mailing Address - Country:US
Mailing Address - Phone:612-581-6655
Mailing Address - Fax:651-633-9485
Practice Address - Street 1:2677 INNSBRUCK DR
Practice Address - Street 2:SUITE D
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55112-6395
Practice Address - Country:US
Practice Address - Phone:612-581-6655
Practice Address - Fax:651-633-9485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1768251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN420247300Medicaid
MN680000517Medicare PIN